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Presidential address: The American Board of Vascular Surgery

1998; Elsevier BV; Volume: 27; Issue: 2 Linguagem: Inglês

10.1016/s0741-5214(98)70350-7

1097-6809

James C. Stanley,

Peripheral Artery Disease Management

Vascular surgery has evolved by quantum leaps during the past five decades. The scientific practice of vascular surgery is exceedingly complex and, combined with the intricacies of dealing with health care providers and well-intentioned social planners, as well as diverse distractions by both our surgical and medical colleagues, challenges the simplest of our efforts. This dissertation addresses an important event in our history, the formation of the American Board of Vascular Surgery, the seeds of its evolution, the reactions to its inception, and a reflection as to what it means to our patients and our discipline. Development of a specialty in any profession fosters greater in-depth knowledge and advances the field's stature, but it carries the additional caveat in medicine of enhancing patient care. Unfortunately, in some surgical disciplines greater knowledge and more visible stature at times do not appear to have improved care of the patient. This has been of great concern to many of us in leadership positions in your Societies. Some attribute this to a belief that specialists can't render total care and that patients in general will be poorly served by such specialists who have fragmented the system. I don't accept this tenet or its implication. Others believe that mediocre performance of subspecialty care is an increasing problem. I do share their concern. A few facts seem incontestable. First, extraordinary amounts of new information have caused many surgeons to specialize simply in order to maintain basic competence in their clinical practices. Second, specialists who undertake greater numbers of specific procedures usually achieve better outcomes. Third, although the generalist was by necessity important because of inaccessible specialty care decades ago, contemporary information systems and economical means of transportation have made specialized care available for most of society. This is not to discount those impoverished or uninsured individuals who have difficulty gaining access to any health care providers, be they generalists or specialists. The American Board of Vascular Surgery had its roots in our Societies long ago. Specialty training in vascular surgery became the focus of attention more than 25 years ago by leaders of both The Society for Vascular Surgery (SVS) and the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS-NA). Edwin J. Wylie in 1970 suggested that standards of excellence for vascular surgery could be reached by the establishment of specific residency training programs,1Wylie EJ. Vascular surgery: a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (32) Google Scholar and the need for these programs was echoed in 1971 by Jack A. Cannon, who noted that lack of proper training and operations performed by occasional vascular surgeons did not serve patients well.2Cannon JA. Surgical judgment in vascular surgery.Arch Surg. 1971; 103: 521-524Crossref PubMed Scopus (11) Google Scholar During this same time period, James A. DeWeese, F. William Blaisdell, and John H. Foster had been appointed as a committee of the Inter-Society Commission for Heart Disease Resources under the auspices of the American Heart Association. In 1972 they published a classic document on methods to provide optimal training and practice in vascular surgery, including a recommendation that certifying bodies of the American Board of Surgery (ABS) and the American Board of Thoracic Surgery (ABTS), or a sub-board of either or both boards, develop examinations in vascular surgery.3DeWeese JA Blaisdell FW Foster JH. Optimal resources for vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (45) Google Scholar Over the next few years the issue of training and certification was discussed widely among members of our Societies, and in 1972 Keith Reemtsma and Dr. Wylie submitted a resolution approved by both Societies recommending that the ABS issue certificates in vascular surgery. Both the American College of Surgeons and the American Surgical Association lent support to this recommendation, and in 1973 Dr. Wylie presented his proposal to the ABS, which approved his resolution in principle but asked for a more detailed proposal. Dr. Wylie presented his revised proposal to the ABS in 1974, yet the board was still not prepared to proceed with certification of vascular surgeons. Instead they established a standing committee to be known as the “Committee for Vascular Surgery,” which at the time of its inception included Dr. Wylie, Jessie E. Thompson, D. Emerick Szilagyi, and W. Sterling Edwards. The ABS Committee for Vascular Surgery wasn't able to move the ABS. No further action on Dr. Wylie's proposal was taken during the next year by the ABS, nor was there any action after a second year. At that juncture, the Joint Council of the two vascular Societies appointed its own committee on vascular surgery training. The response of the ABS 1 week after the establishment of our committee was that discussions of certification of vascular surgeons were premature and should not be considered at that time. Three years had been spent in developing guidelines for training programs that were not acceptable to the ABS. Nevertheless, a year later these guidelines were accepted by the Residency Review Committee in Surgery (RRC-S) given the earlier general support of the American College of Surgeons and the prior acceptance in principle by the ABS. This was remarkable and acknowledged that vascular surgery training was different.4DeWeese JA Vascular surgery—Is it different?.Surgery. 1978; 84: 733-738PubMed Google Scholar This RRC-S training program proposal was forwarded to the Liaison Committee for Graduate Medical Education (LCGME), the group required to accept the guidelines for training programs, but the proposal was tabled because of an objection from the ABTS. Furthermore, the LCGME was not in a position to approve a training program for which there was no certificate, and the ABS was not about to provide one at that time. At that point, in 1979, the presidential address given by Dr. Blaisdell to The Society for Vascular Surgery challenged the vascular surgery community to proceed and assume a leadership role in establishing minimum standards of training in vascular surgery.5Blaisdell FW. Vascular surgery training: Quo vadis.Surgery. 1979; 86: 783-790PubMed Google Scholar That year the Societies proposed their own committee to proceed with evaluation and accreditation of vascular surgery training programs composed of Edwin J. Wylie, James A. DeWeese, W. Sterling Edwards, H. Edward Garrett, and Jessie E. Thompson, the so-called “Program Evaluation and Endorsement Committee”—the PEEC group. In 1980, perhaps because of this self-generated activity on behalf of the Vascular Surgical Societies, the ABS, the ABTS, and their two corresponding RRCs changed their tack and unanimously approved guidelines for training programs in vascular surgery. Final approval by all regulatory groups including the American Board of Medical Specialties (ABMS) occurred in November 1982, more than a decade after the proposal had been initially developed by our Society leadership. In 1982 the first certifying examination was administered to 14 members of the ABS and ABTS, and 2 years later, in 1984, the RRC-S accredited its first training program. In 1984 there was great concern expressed by the leadership of your Societies regarding a number of issues, including representation of vascular surgeons on the ABS and RRC-S, as well as specific case numbers being required to allow individuals to sit for the certifying examination. Sound familiar? That was more than 13 years ago. The seeming resolution of these issues was laborious, but by 1986 the certificate's annotation of qualifications was changed from “Special” to “Added,” and direct admission to the written qualifying examination after training became possible. The designation of “Special” qualifications on the ABS Certificate proved to be a contentious issue. Many on the ABS believed that this was a unique certificate that did not solely relate to the surgeons' performance of vascular procedures, but instead recognized additional special contributions to the discipline of vascular surgery, including research, publications and presentations, teaching of students and trainees, academic appointments, as well as membership and participation in regional and national vascular societies.6Griffen Jr, WO Humphreys Jr, JW Folse JR. Vascular surgery and accreditation.Ann Surg. 1986; 203: 231-235Crossref PubMed Scopus (3) Google Scholar Others, including many leaders of our Societies, believed that this devalued the purpose for the certificate, which was to recognize training in vascular surgery, training that was meant to improve patient care in later practice. The ABS interpretation of what “special” meant clearly made certification elusive to many individuals and created an aura of elitism to the efforts of our predecessors. Transference of this action from the ABS leadership to our Societies did not enhance our reputation among real-world practitioners, but we were not the culprits in this matter. The purpose of my detailing these early happenings between the vascular surgery community and the ABS is to establish the fact that difficulties in communicating and resolving differences of opinion between these groups did not arise during the past few years but have been present since the earliest days of our specialty.7DeWeese JA. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar, 8Garrett HE. Presidential address: evaluation and endorsement of vascular training programs and certificate of qualification in general vascular surgery.Surgery. 1982; 92: 915-920PubMed Google Scholar Nevertheless, progress in the evolution of vascular surgery as a specialty occurred. Much of this progress was due to the effects of many vascular surgeons who served as Presidents of our Societies and Directors of the ABS during the past 25 years, including Drs. Barker, Blaisdell, Connolly, DeWeese, Ernst, Fry, Greenfield, Mannick, Rutherford, Thompson, and Willman. Having had 15 years of experience with formal ABMS-recognized training programs in vascular surgery, it would seem logical to ask what impact this has had on patient care. After all, that's what we're supposed to be all about. On first pass, it appears that care is better, albeit seemingly provided by fewer but better-trained surgeons. Two basic questions must be addressed. Will we continue to train sufficient numbers of surgeons in the United States to care for this country's patients as we enter the next millennium? Will these surgeons provide quality care? My qualified answer is yes to both questions, but only if we and others change the way we train and the way we certify, as well as the way we practice. The first issue I wish to call to your attention relates to numbers. If we attempt to ensure sufficient numbers of physicians to provide quality care of patients with vascular disease, we must understand workforce needs9Ernst CB Rutkow IM Cleveland RJ Folse JR Johnson Jr, G Stanley JC Vascular surgery in the United States: report of the Joint Society for Vascular Surgery–International Society for Cardiovascular Surgery Committee on Vascular Surgical Manpower.J Vasc Surg. 1987; 6: 611-621PubMed Scopus (58) Google Scholar, 10Hobson II, RW Presidential address: practice patterns in vascular surgery—implications for the certification and training of vascular surgeons.J Vasc Surg. 1997; 26: 905-912Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 11Sheldon GF. The health work force, generalism, and the social contract. Ann Surg 222;3:215-28.Google Scholar, 12Stanley JC Barnes RW Ernst CB Hertzer NR Mannick JA Moore WS Vascular surgery in the United States: workforce issues—report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (120) Google Scholar and recognize certain limitations of our current training programs. This issue is particularly relevant because of the 75 million baby boomers' entrance into our patient pool, with an almost unbelievable 73% increase in those older than 65 years occurring from the years 2010 to 2030 and a subsequent increase in operative interventions from 232 to 313 procedures per 100,000 population based on age changes of the United States populace alone. If such were the case, the total number of operations that would need to be performed in 2020 would be 1,020,000. Vascular surgeons were responsible for approximately 51% of the total operations performed 5 years ago, and if the activities per surgeon remain unchanged, then 3042 vascular surgeons would be required to provide 51% of the 1,020,000 operations needed in 2020, yet the product of our current training programs will provide only 2370 such surgeons. That's a shortfall of 672 vascular surgeons. Given the length of training needed to enter practice, we would be required to train nearly 30 additional fellows a year starting now to meet these needs. This seems like a very large number, and I am not advocating that we immediately increase our programs to meet this need. However, I might point out to you that this projection assumes that the general surgeons will continue to also contribute as they have in the past, which does not appear likely. But just say they do, then in 2020 they will be responsible for approximately 150,000 operations. Vascular surgeons will perform approximately 400,000 operations in that year. The total of 550,000 is unfortunately well short of the 1,020,000 operations required by United States society at that time. Who will provide the additional half million procedures? General surgeons, given their own interests, are continuing to enter advanced training in specialties where later vascular surgical practices are unlikely to evolve.13Kwakwa F Jonasson O. The longitudinal study of surgical residents: 1993 to 1994.J Am Coll Surg. 1996; 183: 425-433PubMed Google Scholar In addition, individual malpractice costs as well as restriction of hospital privileges to perform vascular surgery because of institutional liability support the tenet that the small numbers of vascular operations performed by general surgeons today could well become smaller, which would place an even greater workload on the vascular surgery community. Because the numbers required to train general surgeons are mandated by RRC-S criteria, many of us as teachers are boxed in without sufficient operative cases available at many institutions to train additional ABS-eligible vascular surgeons. Limitations in the ability to train additional vascular surgeons is unfortunate, because the data are clear that most general surgeons do not use their training experiences in vascular surgery to care for patients with vascular disease in their later careers. To a lesser extent, this is magnified by an inability to certify vascular surgeons who completed training in PEEC-approved programs that were not RRC-S–approved because their institution did not provide for general surgery training.14Dardik H. Training of vascular surgeons: the two-class system.J Vasc Surg. 1993; 17: 967-970Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 15Friedmann P. Class and conflict in vascular surgery.J Vasc Surg. 1993; 17: 975-976Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The ABS has remained steadfast in its perception that the totally trained general surgeon at the completion of residency is able to perform vascular surgery well. They may be well trained, but they don't carry this into their practice.12Stanley JC Barnes RW Ernst CB Hertzer NR Mannick JA Moore WS Vascular surgery in the United States: workforce issues—report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (120) Google Scholar, 16Mannick JA. Who killed general surgery?.Ann Surg. 1990; 212: 235-241Crossref PubMed Scopus (9) Google Scholar, 17Wheeler HB. Should vascular surgery become an independent specialty? Implications of data about operative experience.J Vasc Surg. 1990; 12: 619-628Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar It seems critical to differentiate surgical training from surgical practice. This becomes a societal problem if we use case material to train but we don't produce a surgeon who will care for these patients. Even when you modify future operative needs by 20% or 30%, which might indeed occur with mandated changes in health care or introduction of new technology such as endovascular therapies, we still fall short in the predicted number of vascular surgeons available to care for society's needs in 2020. Quality care is the second issue I wish to call to your attention. Data do not favor the occasional surgeon performing vascular surgery. Endarterectomy of the carotid artery is a good example. It is among the most common vascular surgical procedures performed, the indications for it are reasonably well defined, the technical challenges of the procedure are not great, and many practitioners believe they are vested in the requisite skills to perform this procedure. Nevertheless, data document that those who perform fewer operations have much poorer outcomes than those who perform this procedure on a regular basis, and the latter are predominantly vascular surgeons, not general surgeons. In the State of Iowa, where there appeared to be an unacceptably high stroke rate after carotid endarterectomy, a careful audit of actual medical records, not a review of discharge data, on all 806 carotid endarterectomies performed on Medicare patients in 1994 revealed a combined cerebrovascular accident and mortality rate for procedures performed by ABS-certified vascular surgeons of 5.2% compared with 8.4% for procedures performed by nonvascular surgeons (personal communication, Timothy F. Kresowik, MD, University of Iowa and the Iowa Foundation for Medical Care). The 3.2% difference represents an incremental increase in stroke and death in excess of 60%. I would ask you the simple question whether it is reasonable for a patient to accept a 3.2% risk of having a stroke or losing one's life just for the convenience of being treated by someone who believes that they are well trained in this procedure, compared with a vascular surgeon who has outcomes that are substantially better. We are not talking about turf or egos, and we shouldn't be talking about economics; we are talking about lives and the benefits of specialization as they relate to one of the most simple technical procedures in vascular surgery, certainly much less complex than the performance of an abdominal aortic aneurysmectomy or infrapopliteal bypass grafting. Norman R. Hertzer was absolutely correct in his presidential address to us 5 years ago—results mean everything.18Hertzer NR Presidential address: outcome assessment in vascular surgery—results mean everything.J Vasc Surg. 1995; 21: 6-15Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Experiences such as those in Iowa do not favor treatment by the nonvascular surgeon. Either we need to train these surgeons differently or they need to practice differently. The Strategic Planning group of your Societies, composed of the two Past Presidents, the two current Presidents, the two President-Elects, as well as the two Secretaries, met after the 1996 annual meetings and considered how to establish a more forthright and effective dialogue with the ABS and RRC-S. It was in an attempt to resolve these issues of numbers of surgeons and the quality of their care that your leadership concluded that carrying on as usual would not suffice; they believed that pursuit of a new Board for vascular surgery was an appropriate evolution of our specialty.19Veith FJ. Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-18Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar In September 1996, the eight of us—William A. Abbott, William H. Baker, Jerry Goldstone, Robert B. Smith III, Jonathon B. Towne, Frank J. Veith, Anthony D. Whittemore, and myself—proceeded with the incorporation of the American Board of Vascular Surgery. This action was carefully conceived with legal counsel and quiet input from many others. It was meant as a preemptive move. We own the name of the Board. The cost of creating this Board and the effect it would have on our influence on American medicine were carefully weighed, and we felt confident that this was the right thing to do and the right time to do it. Our action was subsequently announced to the Executive Committee of the Program Directors in Vascular Surgery; Robert W. Barnes as President of the Program Directors in General Surgery; Calvin B. Ernst and Richard H. Dean, representing two vascular surgeons on the ABS; Jay Grosfeld and Wallace P. Ritchie, Jr., the Chairman and Executive Director of the ABS, respectively; and Paul A. Ebert, Director of the American College of Surgeons. This occurred during a series of sequential meetings on the same day in October 1996. The response to our action might have been predicted. It caused considerable unrest among certain general surgeons. However, it subsequently resulted in a number of ABS and RRC-S reactions addressing symptoms of our past concerns. Many of these responses are viewed favorably by your leadership, including the option to recertify in general surgery rather than having it as a mandatory requirement before recertification in vascular surgery; RRC-S tabling of the requirement of specific numbers of aortic cases to be performed by all general surgeons, which would have placed nearly a quarter of vascular surgery training programs in jeopardy; and the appointment of two vascular surgeons to the RRC-S and the anticipated appointment to the ABS of an additional vascular surgeon to be nominated by the Program Directors in Vascular Surgery. These actions have been a welcome respite, but they don't get at the root of our concerns, namely, the issues of trainee numbers and quality of patient care. The ABS Executive Director's missive of March 1997 was not viewed favorably by your leadership. This document, sent to the approximately 28,000 ABS certificate holders, misinterprets the actions of the vascular surgery leadership. Dr. Robert B. Smith III, my counterpart as President of the North American Chapter of the International Society for Cardiovascular Surgery, and myself first met with the Executive Director and Chairman of the ABS in October 1996 and clearly stated that we did not believe that the training of general surgeons in vascular surgery should be eliminated, although it should be modified. We made this matter plentifully clear by stating that should the vascular community have a Board succeed, a contractual agreement with the ABS and RRC-S mandating continued training of general surgeons in vascular surgery should exist for at least two decades. How this could be interpreted to represent our lack of interest in the training of general surgeons is not apparent. Although this ABS communication may have represented a defining moment for the ABS, it polarized much of the general surgery and vascular surgery communities and jeopardized open and truthful dialogue between the ABS and the vascular surgery community. We have not gone as public in our response to the ABS as did their Executive Director, but we have communicated to him directly in writing and have made a number of our specific concerns known to the ABS through correspondence from one of their Directors, Calvin B. Ernst, who had been nominated to the ABS by our Joint Societies. The vascular surgeons who represent your Societies are not intellectual terrorists. Our concerns are that lives are at stake, not reputations of organizations or the egos of their leadership. The ABS through their recent communication revealed an exceptional talent for making vascular surgeons look petty, but in the rush to condemn us two things were forgotten—our surgical trainees and our patients. The hubris that the ABS should be applauded for being the arbiter and caretaker of vascular surgery's future is not borne out by their actions of the past 25 years. We should dutifully avoid the unwarranted glee, as well as undo pessimism, that prevails in some circles surrounding our recent dealings with the ABS. Respect for the ABS should not be viewed as a compromise, and recognition of all that they have done for our discipline is not a capitulation to their directives. We really should not be at odds with the ABS. We need a solution, not hierarchical dictates from anyone, be they from ourselves, other surgical organizations, or the ABS. Time is not a luxury in this effort. Given the changing face of medical practice, indolence may be the greatest threat to our specialty. We will not keep our vigor and coherence if we are too timid to engage, challenge, or inspire. In our last public communication to you, which was published in modified form in the February 1997 issue of the Journal of Vascular Surgery, the leadership of The Society for Vascular Surgery, the North American Chapter of the International Society for Cardiovascular Surgery, and the Association of Program Directors in Vascular Surgery asked for your support at pursuing our request to establish a primary Board within the ABMS.20The American Board of Vascular Surgery: rationale for its formation. J Vasc Surg 25;411-3.Google Scholar It was signed by the Councils of both Societies and the Association of Program Directors in Vascular Surgery. There have been few times in our recent history that such unanimous resolve has been publicly expressed. The response to this communication from the Society members residing in the United States was enlightening and revealed differences among vascular surgeons who were ABS-certified and those who were not, as well as differences by the age of those queried (Table I). Table IResponse of SVS and ISCVS-NA membership request for support in pursuit of ABMS recognition of The American Board of Vascular SurgeryAge of RespondentsTotal34 to 3940 to 4950 to 5960 to 6970 to 7980 to 8990 to 95All membersYes9063128629319877192No23113364883960Undecided13953344341670Did not respond408233931231173371684Members with ABS Vascular CertificateYes644312562321103320No600222214310Undecided63529229100Did not respond482161710300814Members without ABS Vascular CertificateYes262030618844172No17111142743650Undecided760422251570Did not respond36001776113114337869 Open table in a new tab A total of 1276 replies were received, of which 139 or 11% were undecided. Among those who rendered an opinion, 906 favored our actions and 231 did not. Thus 80% of those members with an opinion favored the formation of the American Board of Vascular Surgery. Perhaps most important were the responses from the questionnaires sent to the 815 Society members who hold ABS certificates in vascular surgery. Responses were received from 767 such members, with only 48 failing to reply. Among those ABS-certified vascular surgeons who responded, 644 favored our action, only 60 disapproved, and 63 were undecided. Thus of ABS-certified vascular surgeons who rendered an opinion, 91% favored pursuing ABMS recognition of the American Board of Vascular Surgery. This ABS-certified group was decidedly younger than the noncertified respondents and are likely to be the future voice of our Societies. This positive response would not have been predicted a little over a decade ago,21DeWeese JA. Presidential address: the vascular societies How involved should they be?.J Vasc Surg. 1986; 3: 1-9PubMed Scopus (8) Google Scholar but the inevitability of vascular surgery having its own Board and RRC was predicted by Dr. DeWeese, one of our most knowledgeable leaders, a year ago on the 50th anniversary of the Society for Vascular Surgery.7DeWeese JA. Accreditation of vascular training programs and certification of vascular surgeons.J Vasc Surg. 1996; 23: 1043-1053Abstract Full Text Full Text PDF Google Scholar The scope of establishing the American Board of Vascular Surgery has been politically tedious, if not daunting. Although the proposed American Board of Vascular Surgery meets the ABMS criteria to become a Primary Board,221997 Annual Report of Reference Handbook. : American Board of Medical Specialties, Research and Education Foundation, Evanston, Ill1997: 74-76Google Scholar discussions by the eight of us who founded the Board on your behalf have included consideration of establishing a Conjoint Board rather than a Primary Board. From an operational perspective, a Conjoint Board is similar to a Primary Board in that it defines criteria for individuals to sit for examinations and it certifies those who pass these examinations. It may also request development of a Residency Review Committee for its Specialty. The difference between a Primary Board and Conjoint Board is that the Directors of the Conjoint Board are appointed by one or both of two sponsoring ABMS Boards,231997 Annual Report of Reference Handbook. : American Board of Medical Specialties, Research and Education Foundation, Evanston, Ill1997: 108-109Google Scholar which in our case would be the ABS and the ABTS. The ABTS has a great deal at stake in what we do regarding further specialization and training, in that 35% of their certificate holders currently perform 50 or more vascular procedures a year.24Cohn LW Anderson RP Loop FD Fosburg RG Cunningham JN Laks H. Thoracic surgery workforce report.J Thorac Cardiovasc Surg. 1995; 110: 570-585Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Appointment of directors by the ABS and ABTS to the American Board of Vascular Surgery as a Conjoint Board would come from nominations from Societies such as ours, the Program Directors in Vascular Surgery, the Regional Vascular Societies, the Advisory Council for Vascular Surgery of the American College of Surgeons, and other organizations with direct interests in the treatment of vascular disease. The policies of a Conjoint Board must be in conformity with those of the two sponsoring boards, yet the day-to-day operations would not be hindered by the reoccurring problems that have existed with those presently responsible for controlling our training programs and certifying us as practitioners. This is a positive situation from our perspective, in that the ABS will maintain indirect control of one of the important parts of the Discipline of Surgery. Furthermore, the ABTS will be included in dealing with relevant training and practice issues much more than they have with the ABS and RRC-S. It also will be very positive for us, in that we will be operationally able to function in a more efficient and independently effective manner. Novel and more timely adaptation of training programs are certainly going to be necessary at meeting our discipline's needs in the years ahead.25Moore WS Clagett GP Hobson RW Towne JB Veith FJ. Vision of optimal vascular surgical training in the next two decades: strategies for adapting to new technologies.J Vasc Surg. 1996; 23: 926-931Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Our mission should be to maintain and improve the health care of patients with vascular disease, and we should not, by choice, expend considerable energy on political polemic. However, if we don't address the issues as to whether we will have enough vascular surgeons properly trained to care for patients as we enter the next century, then we will have been derelict to our profession and to society. The ABS and RRC-S face many difficulties, only one of which is the challenge that has been laid before them by your Societies' leadership. Most of these relate to residency and fellowship training issues, but they all have arisen because the current educational process is in need of restructuring.26Barnes RW. The Residency Review Committee for Surgery and the training of vascular surgeons.J Vasc Surg. 1993; 17: 971-974Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 27Barnes RW Ernst CB. Vascular surgical training of general and vascular surgery residents.J Vasc Surg. 1996; 24: 1057-1063Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 28Ernst CB. Vascular surgical training of general surgeons.J Vasc Surg. 1990; 12: 95-98PubMed Scopus (8) Google Scholar, 29Pories WJ Aslakson HM. The surgical residency: the job description does not fit the job.Arch Surg. 1990; 125: 147-149Crossref PubMed Scopus (22) Google Scholar, 30Ritchie Jr., WP What the future may hold for general surgery: a position paper of the American Board of Surgery.J Am Coll Surg. 1995; 180: 481-484PubMed Google Scholar Specialization will invariably cause some degree of fragmentation, and certification in the real world provides improved opportunities for physicians as they attempt to gain hospital credentials. The former may have its downside to clinical care, but the latter may result in better care, although its misapplication would be most unfortunate. The Vascular Societies have been very direct at suggesting guidelines for hospital privileges that are not related to Board certification.31Moore WS Treiman RL Hertzer NR Veith FJ Perry MO Ernst CB. Guidelines for hospital privileges in vascular surgery.J Vasc Surg. 1989; 10: 678-682PubMed Scopus (33) Google Scholar These are not new issues, but they must be addressed. It may not be my place, but I personally believe that the ABS should seriously consider changing the manner with which it appoints its Directors, such that they are elected so as to more likely represent the specific specialty components of surgery rather than various popular leaders of established academic and clinical societies. It would also be my personal advice that they consider a different manner of managing training and certification issues related to surgical oncology, hepatobiliary and gastrointestinal surgery, critical care and trauma, transplantation, and endocrine surgery. These subspecialties should have a venue that provides them with greater responsibility and, most importantly, the authority to define how surgeons are trained and certified in their special areas of practice. Like certain of my predecessors, I strongly believe that vascular surgery should continue to be a part of the training of general surgeons.32Fry WJ. Vascular surgery: a brief look back and then to the future.J Vasc Surg. 1984; 1: 3-5PubMed Scopus (6) Google Scholar, 33Mannick JA Presidential address: vascular surgery—“A part of the main.”.Surgery. 1981; 90: 927-931PubMed Google Scholar However, I do not believe that vascular surgery should continue as a primary component of this training. Furthermore, because of practice issues related to better patient care, the vascular surgery community should be respected for having evolved to the point where a greater degree of independence as a Conjoint Board deserves support. Your leadership has met with many individuals and organizations during the past 9 months and has concluded this year with three commitments. First, we believe that the Curriculum Committee and Conjoint Data Committee, developed by us in recent discussions with the ABS and others, should continue their work, with a definitive report from them expected by the October 1997 Joint Council Meeting of your Societies. Second, we will defer until February 1998 submission of our application to the Liaison Committee for Specialty Boards to become an ABMS Board. The completed application will remain unpublicized in our hands, but there is a time frame. Third and last, we will request support for a Conjoint Board from our colleagues on the ABS and ABTS. The logic in creating a Conjoint Board is solid, and benefits would be derived by both of the latter organizations in supporting the vascular surgery community in this action. Closure on this effort will likely be measured in years, not weeks or months. We have the support of many nonsurgeons in the ABMS to pursue Board status. We need the support of many of our surgical colleagues. We are not elitists, and we are not combatants. In fact, we are a lot like everyone else—we care about the discipline of surgery and our patients. Vascular Surgery is no longer in its adolescence. It is a mature specialty with major obligations to society. We must not fail in meeting these obligations.